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What Happens When You Have a Workers’ Compensation Claim?

Originally published by Eastern Alliance

  • The goal of the workers’ compensation system is to help injured workers receive the appropriate medical care and return to gainful employment.
  • While the state specifies how many hours or days an employer has to report an accident, the insurance carrier should be notified immediately whenever there is a workplace injury. The faster the carrier receives notice of an injury, the faster the injured worker can access the most effective medical care.
    • OSHA and/or the state workers’ compensation board may need to be notified as well.
    • Many employers are required to keep injury and illness records.
    • When a fatality occurs in the workplace, within eight hours after the employer learns about the event, OSHA must be notified, regardless of the size of the employer or its industry.
    • All employers are required to report any work-related inpatient hospitalization, amputation or loss of an eye, within 24 hours after the employer learns about the event.
  • The carrier generally helps file a First Notice of Injury with the appropriate state agency.
  • There are two components to claim costs: medical costs (compensation for medical care) and indemnity costs (compensation for income lost while the injured worker was unable to work). When a claim involves indemnity costs, it is sometimes referred to as a “lost-time claim.” When the claim occurs, the insurance carrier will set aside reserves for the accident, based on its prediction of the money that will be needed until the claim is settled.
  • States vary in their regulations regarding treatment guidelines, ability to direct care, impairment categorization and compensation, duration of benefits, and so forth.
  • When an injury results in permanent partial or total disability, continuing benefits may be paid depending on state regulations.
  • Some states permit full and final settlements; some require “lifetime medical” benefits. Workers may be permitted to re-open a claim if they aggravate the injury or experience a worsening of the condition.
  • When an accident results in a fatality, most state regulations provide death benefits for certain family members to compensate for the loss of financial support.